March 19, 2005

Heart transplant success story

The outcome of heart transplants in patients with schizophrenia is unknown, mainly because having a diagnosis of schizophrenia is an automatic exclusion criterion for heart transplant in most transplant programs worldwide. Here a case is presented of a young man with schizophrenia who was initially denied a heart transplant because of assumptions about his psychiatric vulnerability, his ability to communicate, and his likelihood of complying with complex posttransplant treatment. The authors claim that there was little objective information to support these assumptions, and so in this article they describe Mr. A’s case and how it was brought before an ethics committee resulting in the overturning of the initial rejection. They also describe the subsequent successful medical and psychiatric outcomes of the heart transplant operation.

Mr. A, is a 37-year-old African American single man who lives with his mother, two brothers, and a sister and has been treated in his neighborhood outpatient psychiatric clinic for 15 years. He is unemployed and supported by Supplemental Security Income. He attended special education classes until age 16 when he dropped out of school when his schizophrenia symptoms began.

A few years ago, when Mr. A was rushed to an emergency room, it was discovered that he had full-blown congestive heart failure. While he was hospitalized, his treatment team at the psychiatric clinic raised the question of his eligibility for a heart transplant. The consultation service felt that Mr. A would not be a good candidate for a transplant since he couldn’t communicate clearly, had schizophrenia with persistent psychotic symptoms, could have worsening psychotic symptoms due to immunosuppressive medications and may not be able to adhere to his required intensive medical follow-up.

After returning home from that hospital visit, Mr. A kept all of his cardiac appointments but required five medical hospitalizations and three psychiatric hospitalizations due to worry in the year that followed. He became sad and said that if he died, he wanted to die at the clinic, which was both endearing and discomforting for the staff and patients and difficult for his family. The psychiatric team then decided to present his case to the chairperson of the general hospital’s ethics committee for reconsideration of a heart transplant. Upon reconsideration, they concluded that the only criteria for denying Mr. A’s heart transplant were 1) the transplant would not improve the quality of his life which was ruled out because he had no other significant medical problems and 2) he could not comply with the rigorous treatment protocols and the follow-up care required after transplant. This second criterion was ruled out because Mr. A had a supportive family, a psychiatric treatment team and about 80 fellow patients who were more than willing to do whatever was needed to help Mr. A comply with post-transplant care. The ethics committee concluded that there was no compelling reason to not present his case for a full heart transplant evaluation and he was accepted for a heart transplant.

His operation was paid for by an anonymous hospital benefactor who had donated money to cover a heart transplant for a patient who could not afford it. After the operation, Mr. A did well and returned home 24 days later and a week after discharge was able to attend the clinic Christmas party wearing a surgical mask. Since then, he has functioned well for more than 3 years with no significant medical complications from the transplant, and without any significant psychiatric exacerbation. He has been compliant with his medical follow-up and attended all of his weekly cardiac biopsy appointments. When asked about his heart, Mr. A said, "My old heart was not working so I got a new one." and then while smiling added, "My new heart came from a 16-year-old boy. That makes me younger!"

This story highlights how an attitude of denying organ transplants because of a diagnosis of schizophrenia and stereotypical judgments can contribute to increases in death among patients with schizophrenia. In a survey of heart transplant programs throughout the US, it has been found that there are many discrepancies among programs regarding inclusion criteria and rates of refusals. Most programs excluded patients on the grounds of active schizophrenia, dementia, current suicidal ideation, history of multiple suicide attempts, severe mental retardation, current alcohol abuse, and current use of addictive drugs. But in the couple of other organ transplant cases that have been published, it does not seem that a psychiatric illness interfered with the patient’s ability to stick to treatment or put the patient at a greater risk of medical complications.

The story also highlights that people with schizophrenia have a tendency to often not complain of pain until it is severe (which is what happened with Mr. A), so it becomes important for psychiatrists and patients to be alert to medical complications and try to ensure that they are picked up early and not later in the course of the illness when it more difficult and costly to treat. The field of organ transplantation is growing, yet donor resources are limited. Mr. A’s success story highlights the point that the decision to perform a transplant should be based on the merits of the individual case rather than on the grounds of a preexisting psychiatric diagnosis.

The authors acknowledge the Washington Heights Community Service, New York State Psychiatric Institute, New York-Presbyterian Hospital and the Audubon Clinic.